Proctoring/FPPE (Focused Professional Practice Evaluation)

Accreditation Monthly, December 9, 2008

In traveling from hospital to hospital, I find that the FPPE process is one that is a challenge to comprehend, design, and implement. The lack of an FPPE process is also more consistently cited by The Joint Commission surveyor. It is my hope that the following article will help clarify what is needed and how to begin the process.

A good FPPE process allows a medical staff to bridge the gap between having no firsthand knowledge of a practitioner's competency to one in which we have sufficient information as to allow monitoring of ongoing competency by a peer review process. The FPPE policy should ensure achievement of that goal.

Note: Practitioners requesting membership but not exercising specific privileges do not need to be proctored. This includes your no-volume physicians.

FPPE applies in two cases

  1. When a hospital must confirm competence of a practitioner who is new to the organization (for the purpose of granting privileges). A period of FPPE must be implemented for all initially requested privileges. For practitioners who do not currently have privileges or a track record at the hospital, the medical staff must define the circumstances that require monitoring and evaluation of a practitioner's performance.
  2. For situations in which a concern is identified in regard to the competency or ability to provide care by a practitioner who is not new to the organization. This includes the following circumstances:
    • A known practitioner requests a new privilege that he or she was not previously granted.
    • When questions arise about whether a practitioner can continue to provide safe, high-quality care. In these cases, the medical staff must develop criteria that address when such a review will be triggered. (I often see this included in the medical staff peer review policy. If that is the case, it does not need to be discussed in the FPPE process.)

Performance monitoring process
The performance monitoring process should identify:

  • The criteria to be used for performance monitoring>
  • The method used for establishing a monitoring plan specific to the requested privilege(s)
  • The method used to determine how long the performance monitoring will last
  • Circumstances that require monitoring by an external source

Typically, all or some of the following are identified as FPPE monitoring methods:

  • Prospective proctoring: Presentation of cases with planned treatment outlined for the proctor's treatment concurrence, review of case documentation for treatment concurrence, or completion of a written or oral examination or case simulation.
  • Concurrent proctoring: Direct observation of the procedure being performed or medical management either through observation of practitioner interactions with patients and staff members or review of clinical history and physical and review of treatment orders during the patient's hospital stay.
  • Retrospective evaluation: Review of the case record after care has been completed. May also involve interviews of personnel directly involved in the care of the patient.

FPPE leads to OPPE
As stated above, FPPE is a focused evaluation process to confirm an individual practitioner's current competence at the time new privileges are granted, either at initial appointment or as a current member of the medical staff. In addition to specialty-specific issues, proctoring will address the six general competencies of physician performance. Often, these are the same as identified in your ongoing professional practice evaluation (OPPE) but on a more frequent review—either prospective, concurrent, or retrospective. The six general competencies are:

  • Patient care
  • Medical knowledge
  • Practice-based learning and improvement
  • Interpersonal and communication skills
  • Professionalism
  • Systems-based practice

Medical staff oversight
Your process should include oversight responsibility. Identify which group in the medical staff will have primary oversight of this program (e.g., credentials committee, department chairs, MEC, or other).

Medical staff proctors
Identify the criteria for choosing a proctor.

Data sources and reporting
As stated above, FPPE and OPPE data are often the same information, but what distinguishes FPPE is more frequent and intense monitoring. Data sources often include:

  • Routine chart audits by non-medical staff personnel for important clinical functions
  • Identified procedural or care process documentation review by the proctor
  • Data abstracted for external comparative databases used to evaluate current medical staff members
  • Incident reports
  • Findings of cases identified for review by medical staff peer review committees
  • Electronic claims data used to evaluate current medical staff members
  • Patient satisfaction surveys

Finally, identify the method by which the analyzed data are reported along with recommendations. Most often, the endpoint will be when competency is established so FPPE can be ended and OPPE or the regular monitoring process can take over. The end point needs to be clearly identified in the policy.


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